Page 101 - Hospital Authority Convention 2018

Masterclasses

M6.1 Enhancing Medical-social Collaboration for Elderly 16:15 Convention Hall C
Patients

What Should the Care for Older Persons Look Like by 2028?
Au Yeung TW
Department of Medicine and Geriatrics, Pok Oi Hospital, Hong Kong HOSPITAL AUTHORITY CONVENTION 2018

Now in 2018, we dream by 2028, we can realise: Ageing in place, care in place, and dying in place. To achieve these goals, we
need to build up an infrastructure of ambulatory outreaching service to support and materialise:

“Hospital” at home
“Care home” at home
“Hospital” at care home

This can only be built on a socio-medical collaboration model – integrating medical care with community-based personal
care through empowerment of NGOs to carry out healthcare services, network building between hospital care, primary
healthcare and community health care, geron-technology to assist activities of daily living. Last but not least, IT development
for tele-assessment, tele-health monitoring and support.
Great barriers are in front of us to overcome. They include segregation of welfare and health administration at government
level, medico-legal issues and legislation barrier against “dying in place”, high cost of home-based services, and
medicalisation of ageing and dying. Monday, 7 May 2018

M6.2 Enhancing Medical-social Collaboration for Elderly 16:15 Convention Hall C
Patients
Orthogeriatrics Collaboration at Tai Po and New Territories East Cluster
Lee J
Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong

Collaboration between orthopaedics surgeons and geriatricians is a corporate initiative to face an ageing population. The
vast majority of hip fracture patients are over the age of 75. Many of these suffer other co-morbidities, which required early
medical management to facilitate timely operation. During the post-operative and rehabilitative periods, common geriatric
syndromes such as delirium, retention of urine, unrecognised pain, and poor social support will all hinder recovery and their
ability to return to the community. With these in mind, the orthogeri collaboration programme was started in October 2017 in
Alice Ho Miu Ling Nethersole Hospital (AHNH) and Tai Po Hospital (TPH) in Tai Po.

At the same time, Food and Health Bureau has also recognised the need of these patients and has started funding a
Medical Social Collaboration. This programme links multiple non-governmental organisations to support via a designated
social worker under the Social Welfare Department to provide post-discharge community/social care support, so that
those with poor social or family support can avoid institutionalisation. Another component of this programme is for the
geriatrics outreach team to provide professional case manager service similar to the Integrated Care Model, for home-based
rehabilitation in suitable patients.
Encompassing these two programmes, the geriatrics, orthopaedics, and community outreach service teams at TPH and
AHNH has been working together on a daily basis since October 2017. We would like to share our experience, discuss the
challenges we have resolved, and those we are still facing.

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